EMCrit Podcast 5 – Intubating the Critical GI Bleeder

We’ve had a  few gruesome airways in patients with GI bleeds and bellies full of coffee ground emesis.

This is a top 10 list encompassing my approach to this difficult situation:

1. Empty the Stomach

Place a salem sump and suck out all of the stomach contents.
Varices are not a contraindication (see: Digest Dis 1973;18(12):1032, Gastrointest Endosc. 2004 Feb;59(2):172-8, and Anesth Analg 1988;67:283)

Administer Metoclopramide 10 mg IVSS

2. Intubate the Patient with HOB at 45°

Semi-Fowler’s position will keep the gastric contents from moving up the esophagus

3. Preoxygenate like mad

You do not want to bag these patients, give yourself a preox cushion

4. Intubation Meds

Use a sedative that is BP stable, use reduced doses.

These patients NEED paralytics. You need to optimize first pass success. Paralytic agents actually increase the lower esophageal sphincter tone (Br J Anaesth 1984;56:37).

5. Gather your equipment to optimize first pass

Use fiberoptic laryngoscopy if you have it (e.g. Glidescope)

At the bedside, have a bougie, an LMA, a meconium aspirator (more below), and 2 suction set-ups

Wear eye protection!

6. If you need to bag after a failed attempt…

Bag gently and slowly (10 times a minute)
Consider placing an LMA if you need to bag.

7. If the patient vomits: Trendelenberg

This potentially keeps the emesis out of the lungs

8. Meconium Aspirator

If the normal suction is too slow, attach the meconium aspirator to your ET tube. See this post on a novel ETT suction set-up for the full description.


9. No ABX for Aspiration

Aspiration in the initial phases is a chemical pneumonitis, not a bacterial pneumonia

See Marik’s article (NEJM 2001;344(9):665)

10. SIRS

Expect a sepsis-like syndrome from the aspiration. This folks may need pressors and tons of additional fluid

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  1. says

    great summary scott. additional thought: although you want to not bag, if you must bag, you want to minimize the amount of air transmitted to the stomach. So abort your laryngoscopy attempts earlier so you’re more likely to bag slowly, gently, and, even better – through an LMA.

  2. phil says

    Great checklist for the next UGIB intubation, Scott.

    As I watched an oropharynx fill with coffee grounds a couple months ago, I was reminded of that really large bore perforated suction catheter on display at an ACEP SA past. Couldn’t find it just now, after doing a quick search online, but a larger bore catheter and tubing would go along well with the meconium aspirator.

  3. Taku Taira says

    I would add that this is a time that you want to have a blind technique ready like the Intubating LMA… although a bougie is technically a blind technique ILMA, would be better… (saved me the last time i saw a mouth full of blood despite 2 yankauers)

  4. Mike says

    Scott, I just had a woman with right sided lung CA who developed MASSIVE hemoptysis…actually was just pouring out blood from lungs. She quickly went into respiratory arrest then cardiac arrest. We suctioned 500 mL of blood from her mouth and airway in the first 3 minutes. I called anesthesia (first time I ever thought I wouldn’t be able to intubate someone), couldn’t find a meconium aspirator, but anesthesia intubated anyway, though we couldn’t confirm due to amount of blood. Then of course we couldn’t ventilate her. She died, and I think it was 1. from respiratory then cardiac arrest and no ventilation or 2. bled to death.

    What I was wondering was if you had any suggestions of handling this? I’ve heard of single sided bronchus intubation but neither anesthesia nor I knew how to do it. Any suggestions, or was she doomed from the beginning? Thanks, love your podcast and learn something every episode.

  5. Kevin Spencer says

    I have said before… Love your podcast. So yesterday I just had a GI bleeder that started crashing, but was able to stabilize and thankfully didn’t have to intubate.

    Now in hindsight I am here reviewing the “what if’s” and googling “Intubate the GI Bleeder”, and the first thing that pops up on google is this podcast, which it turns out I have alreaded downloaded onto my iPhone (along with all your podcasts), but hadn’t yet listened to this one. So, thanks again for this (and every) posting, please keep them coming.

    This brings me to my question: Any chance you can do a top to bottom review of the ER variceal GI Bleed management (beyond the airway, which you have covered)? Would love to see your algorithm and rational with regards to octreotide, FFP, Pantoloc, etc…

    • says

      wow, never saw it. That is great! I bet it is much more expensive than a meconium aspirator and suction port for in-hospital use.

  6. Michael says

    Is there any reason you couldn’t place an OG instead of NG prior to RSI/DSI? I’m a paramedic and all we have are OGs. If you can, would you be better off doing this after a low dose of ketamine or prior to any sedation?

  7. Jay Matthew says

    Whilst doing a summary of this podcast for our doctors at work, I thought out this mnemonic which I thought would help perhaps: Intubating these patients is NO CHRISTMAS!
    CH=chest and head elevation (45 degrees)
    R=RSI meds
    I=intubation success (first pass)
    S=slow, gentle BVM if failed
    T=Trendelenberg, if vomits
    M=meconium aspirator
    A=antibiotics not indicated early
    S=SIRS response expected
    What do you think??

    Love your podcasts, by the way…it’s like a bible for our unit in South Africa!!

    • says

      Not sure why it needs to be part of DSI. By all means give the med, but don’t need to link it to the stressful moment of peri-intubation. It is the NGT that is doing the work, not the reglan.

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